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The Clinical Documentation Improvement (CDI) Add-on provides essential information to assist coders in the translation of clinical documentation for complete and accurate coding, as well as assisting clinicians in thorough documentation at the point of care for proper code identification. This content, provided by code, helps ensure clinical quality, substantiate medical necessity, and aids in justification for appropriate reimbursement. Health record documentation as designated by the clinician is the foundation upon which coding decisions are based.

As a result, accurate understanding of this documentation and a clear record upon presentation of the patient are critical. With the specificity of ICD-10-CM and PCS, and the increased level of detail necessary for proper code selection, the documentation driving code assignment must be just as detailed and provide accurate information for reimbursement justification. Read more

Identify and clarify. Any confusing, incomplete, conflicting, or missing information in the physician-documentation portion of the health record that is related to diagnoses or procedures can be found and corrected.

Search clinical terms, codes, keywords, and print and/or email. More precisely document that which can be necessary for clinicians, coders or any other healthcare individual needing information for accurate code identification and a more robust and accurate depiction of patient severity.

Foster and enhance communication. Create a better dialogue between members of the CDI team, coders, and medical staff.

Provide ICD-10-CM education to medical staff members on the increased granularity inherent in ICD-10-CM. Explain how more detailed documentation in the medical record is needed, as well as educating coding staff members clinical knowledge as it relates to the specificity in the new code set.

Provide continuity of care. Build consistency for the patient and between members of the healthcare team that rely on documentation in the health record for determining ongoing treatment decisions.

NOTE: This item is an Add-on to our suite of online products. This item may only be purchased if you are also buying a subscription to an online application.

If you are already an active subscriber to one of our online coding applications and you are interested in purchasing an Add-on, please contact a customer service representative at 1.800.464.3649, option 1.

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Content Experts

Ryan graduated from the University of Utah in healthcare administration and has worked for multiple commercial payer organizations in several different roles. Additionally, Ryan worked as a practice administrator for a physician clinic, where he implemented an EMR system and a fully electronic coding and code review process. For the past 10 years, Ryan has designed and managed medical coding data management systems, workers compensation rebilling systems and medical coding/fee schedule software.